Practice Continuity Guide for Family Physicians

Practice Continuity Guide FOR FAMILY PHYSICIANS

Is your practice prepared for an emergency or disaster?

GUIDE (BOOK 1 OF 2) a guide to creating your own practice continuity plan

Acknowledgments This Practice Continuity Guide for Family Physicians was developed in partnership with the B.C. Ministry of Health Emergency Management Unit and the Victoria Division of Family Practice.

We would like to thank all members of the Victoria Division of Family Practice and other partners who provided input and suggestions for the development of this guide.

Dr. Ian Bekker, physician lead Dr. Herbert Domke Dr. Ranald Donaldson Dr. Haydeh Erfanifar Dr. George Forster Dr. Carol Jenken Dr. Hana Masata Dr. Peter Meyer Dr. Tejinder Sidhu Dr. Ioana Smirnov Dr. Lorne Verhulst Dr. Jody Young

Shawn Carby, Ministry of Health Katja Magarin, Ministry of Health Sue Munro, Island Health/Provincial Health Services Authority Eileen Grant, District of Oak Bay Catriona Park, Project Coordinator Crystal Sawyer, Editing & Design

Table of Contents

Purpose

BOOK 1: GUIDE – Practice Continuity Plan Guidebook

Use BOOK 1: GUIDE to understand how to create your own plan.

1. Introduction

1

2.

Plan Development

3

3.

Before an Emergency

5

3.1

Prepare Different Types of Emergency Kits

5

3.2

Emergency Office Procedures

7

Use this guide’s companion,

3.3 Insurance

9

3.4

Staff Contact List and Communication Plan

11

BOOK 2: WORKBOOK

3.5

Identify Essential Services

11

3.6

Critical Records Inventory

13

3.7

External Services and Suppliers—Contacts

13

3.8

Updating Your Plan

4.

During and After an Emergency

15

4.1

15

 Checklist

16

5.

Putting the Plan Together

16

Rapid Damage Assessment

6. Resources

14

17

BOOK 2: WORKBOOK – Practice Continuity Plan Template 7.0 Creating Your Practice Continuity Plan

7.0.1 Preparing Different Types of Emergency Kits

7.0.2 Emergency Office Procedures

7.0.3 Insurance

7.1 Staff Contact List and Communication Plan

1–5 2 3 4–5 6–11

7.2 Essential Services

12–13

7.3 Critical Records Inventory

14–15

7.4 External Services and Suppliers - Contacts

16–21

7.5 During and After an Emergency

22–24

7.6 Completion Form

25

to create, alter and expand a plan to suit your practice — make it your own.

You, your Medical Office Assistant (MOA), and other staff likely have most information already available; it is a matter of compiling the information into one readily accessible document.

By the time you are finished, you will have created an essential Practice Continuity Plan.

IT CAN HAPPEN: Arson destroys large part of Vancouver Island strip mall—Sooke, BC | 31 Jul 2013 Early morning fire closes doctors’ offices —Stratford, ON | 20 Jan 2014 Family doctors back in business after fire —Stratford, ON | 7 Feb 2014

SCENARIOS IN THIS GUIDE

CONSIDER THIS: Fire in your clinic It’s the middle of the afternoon at your busy group practice, and there are six patients in the waiting room. Your MOA emerges from the washroom and smells smoke. It’s coming from the ceiling at the end of the hallway. She pulls the fire alarm, and calls 911. The operator instructs her to evacuate the clinic immediately.

Staff and patient safety is the number one priority. One doctor is in the midst of stitching a child’s forehead; another is consulting with a patient. Interrupting these patient care visits adds to the stress of the situation.

Staff grab a first aid kit, calmly and quickly ensure each person moves outside to the clinic’s pre-identified muster or meeting area, and check that everyone is accounted for. There are five other units in the same building, all of which have been affected. The manager of one unit slips running down the stairs, and potentially has broken his leg; you provide him with emergency care.

Suddenly, there is a series of explosions. The fire spreads quickly, and soon much of the clinic is engulfed in flames. By the time the fire department reaches the scene, much of the building is destroyed beyond repair. A new, permanent location will be required in the long-run, but interim quarters are needed now to provide essential services.

Luckily — although all computers and paper-based files were destroyed — a backup of the office’s files is stored off-site at one of the partnering physician’s homes. What are your next steps?

Throughout this guidebook, you will find a number of emergency scenarios, all of which could affect you and your patients.

As you and your MOA review the process of creating your own Practice Continuity Plan, consider these scenarios.

At the back of this guide, you’ll find space to note what steps you would take to mitigate a gap in patient care, to address legal and insurance matters, and to be operational in the shortest period of time.

Consider communication protocols. Who do you need to contact? How will you ensure the questions of staff are answered and the needs of patients are met?

1. Introduction How would your family practice continue to offer care for your patients if there were an emergency or disaster in your building, your neighbourhood, or your region?

Consider the following possibilities if your practice is directly affected because: • A fire in your building destroys all your equipment and files, and you now need to find a new office;

• A pandemic increases patient volume and at the same time your staff members are calling in sick;

• A malfunction in the sprinkler system destroys all your electronic equipment and soaks all your paper files;

• An earthquake shakes your community, affecting your patients, practice, community, and home; or,

• Your electronic medical records (EMR) are compromised and the backup is unusable or out of date;

• Patients show up looking for help, but your staff is gone and the building is damaged.

The best time to plan for an emergency or disaster is before it happens, but the task of actually preparing a plan can seem daunting.

That is why we created this guide — to assist you in the creation of your own Practice Continuity Plan.

A business continuity plan provides you with the information you will need to take care of your staff, to reopen your office, and to get back to helping your patients as soon as possible.

Planning ahead and building resiliency before disaster strikes will allow you to continue to assist your patients and get your office back to normal sooner.

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CONSIDER THIS: Earthquake “Prepare for an earthquake, and you’re prepared for almost everything.”

KATJA MAGARIN | EMERGENCY MANAGER, B.C. MINISTRY OF HEALTH

An earthquake measuring 6.3 on the Richter Scale strikes just 80 kilometres from Victoria. Everyone in the wider region around the epicentre felt the violent shaking. Even well-built structures have sustained considerable damage. Infrastructure throughout the city has been damaged, some roadways are blocked, and pipes in many homes and offices have burst.

Patient volume, especially those with critical or acute injuries, skyrockets.

Hospitals are overwhelmed and demand spills into doctors’ offices.

Power outages are widespread and your EMR is not functioning well. You are treating injuries that you haven’t seen in many years, and supplies are in short supply.

The majority of people have MSK injuries and lacerations, and triaging is necessary. Many patients don’t have access to their usual physicians, and you are working with incomplete medical histories. The B.C. Ferries are unable to dock safely, and so far planes have not attempted a landing. The entire supply chain has ground to a halt.

According to the CRD’s Official Community Plan, there is a 32 percent likelihood of a damaging earthquake in Victoria before 2054. An earthquake could be considered the most challenging emergency situation to prepare for.

Now is the best time to do just that.

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IT CAN HAPPEN: Christchurch earthquake: Latest updates—New Zealand | 25 Feb 2011 Wellington picking up the pieces post quake—New Zealand | 22 July 2013 Australian doctor receives bravery award for amputating trapped man’s legs after New Zealand’s 2011 earthquake—New Zealand | 22 June 2014 Doctor reflects on Haiti’s ‘day of doom’—Haiti | 12 Jan 2015

RESOURCES:

Earthquake preparedness in South Australia—2014 Shakeout B.C. — shakeoutbc.ca

2. Plan Development

SECTION 4 will provide you with a checklist of the necessary steps during and after an emergency.

This planning guide is focused on a one-physician practice that can easily be scaled to an office with more physicians and staff, and to more diverse service offerings.

Planning for an emergency is an iterative process and begins with the basics.

We recommend you address the most important things you require to run your practice as you develop your initial Practice Continuity Plan.

This guide focuses on two important timelines: before an emergency, and after an emergency. In Section 3 you will find the basic steps you can take before an emergency occurs. These include: •

Preparing emergency supplies

•

Documenting emergency office procedures

•

Confirming adequate insurance coverage

•

Identifying essential services

•

Preparing staff contact list and communication plan

•

Preparing critical records inventory

•

Listing contacts for external services and suppliers

•

Considering mutual aid agreements with a colleague

In BOOK 2: WORKBOOK you will find tables and templates that you can copy and complete to form your basic Practice Continuity Plan.

Involve your MOA and other staff in this process. They will likely have much of the required information readily available, and can assist you in gathering it. Working together is an excellent way to ensure everyone knows what to do in case of emergency.

This guide will get you started. It is strongly recommended that you and your staff tailor this plan to suit your own practice.

Let’s begin!

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CONSIDER THIS: Pandemic outbreak An influenza pandemic has erupted in your community, and you are witnessing the effects first-hand at your clinic. There is a sudden increase in patient volume, at the same time when three of your office staff are sick. This imbalance creates an overall strain, not only in your clinic, but throughout the local health care system.

To accommodate the increase in patient volume, you and other clinics have established dedicated care units to treat the infection. Doctors are taking on much higher than usual caseloads. Patients are being prioritized by level of seriousness and degree of risk. Caregivers who are still well are nearing burnout.

At the residential care facility where you also practice, you are extremely concerned about promoting prevention and resilience within your frail and elderly patients.

You are also worried about your own family’s health. Pharmacists report a shortage in prescribed medication, and supplies of facial shields and gloves are running out.

IT CAN HAPPEN: Pandemic influenza and physician offices—June 2007 Flu back for round 2 —Hamilton County, Tennessee | 19 March 2015 Number of influenza deaths in Alberta this season “higher than normal”—Edmonton, AB | 29 January 2015 Primary care physicians’ response to pandemic influenza in Hong Kong—September 2012

RESOURCE: British Columbia’s Pandemic Influenza Response Plan—September 2012

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Think about what you might need to get everyone out safely, how long you could be expected to shelter-in-place, and what would help you to return to work as quickly and effectively as possible, then plan accordingly. You can build your own kits or buy them ready-made.

Items you might include in an emergency kit: Practice Continuity Guide dynamo am/fm radio-style flashlight

3. Before an Emergency

standard flashlights for all members spare batteries for all devices adapters for cell phones and other devices

3.1 Prepare Different Types of Emergency Kits

basic tools (crowbar, utility knife, wrench)

Consider the number of people and for how many days you may need to shelter, and what equipment and supplies are necessary to cover those needs. There are two basic types of emergency kits: Grab & Go and Shelter-in-Place. Each has a different purpose, and should be tailored to your specific needs.

temporary shelter, i.e. tube tents + tarps

Grab & Go Kits are used when you need to evacuate a location immediately, and are intended for periods of six to 12 hours, or until you reach safety.

water purification tablets

• Everyone should have a Grab & Go Kit. You may wish to provide your employees with basics or a monetary contribution to get them started.

• Each kit needs to be purposespecific and designed for either office or home.

• Each kit needs to be personalized with items like important documents, medication, or prescription glasses, and should accommodate special needs and food sensitivities.

• Everyone needs to be counted.

Think about patients who may need to shelter with you in your office, or visitors to your home.

• Don’t forget your pets.

Shelter-in-Place Kits are necessary when you, your employees, or your family must shelter-in-place. In case of a chemical leak or severe weather, local authorities may issue a shelter-in-place order, preventing you from leaving the office for more than 12 hours. A home-based Shelter-In-Place kit is designed to meet your family’s basic needs when sheltering-in-place — often without utilities like electricity or water — is your safest option. Shelterin-Place Kits should meet the needs of employees and families for a minimum of 72 hours. Because Victoria is located on an island and may be cut off for a considerable period of time, that recommendation has been extended to a minimum of seven days.

8-hour glow sticks work gloves, rubber gloves food (ready-to-eat, non-perishable, freeze-dried) water (4L/person/day) collapsible 8L water container 20L bucket toilet seat, chemicals, liners, toilet paper heavy gauge garbage bags biohazard bag hand disinfectant 4L resealable storage bags N95 masks emergency blankets rain ponchos duct tape signal whistles military-style can opener sturdy shoes (at desk, for broken glass or evacuation) whistle & mask (taped under desk)

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CONSIDER THIS: Sprinkler malfunction You arrive early at the office one morning to discover that a sprinkler has malfunctioned overnight. Two of the treatment rooms in the back are flooded with a three centimetre-deep puddle on the floor. There is considerable water damage; all electronic equipment, furniture, medical supplies, paperwork, and carpeting, are ruined.

Other colleagues and staff arrive, and together you mop up, trying to contain the damage. Your MOA contacts patients and promises to reschedule once the situation comes under control.

The office will require extensive restoration. It may be several weeks or months before it is are ready. You contact your building maintenance company, insurance company, and a restoration firm. One of the biggest threats is mould.

A special company that has met clearances to handle confidential patient files needs to be hired. Replacement equipment, such as computers and an ultrasound machine, must be ordered.

In the meantime, electronic medical records are affected, and staff must resort to paper-based charting although they aren’t used to doing so. The shift causes confusion and more stress.

A situation like this can happen any time. Whether the sprinkler is faulty, or is triggered by a fire alarm, or whether a pipe ruptures in the office, a flood can be devastating to any clinic.

IT CAN HAPPEN:

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Flooding closes walk-in clinic for two to three weeks—Kamloops, BC | 7 Feb 2013 Malfunctioning sprinkler system causes water damage to VA—Big Spring, Texas | 14 Oct 2014 Orillia City Centre sprinklers malfunction, flooding municipal offices—Orillia, ON | 25 Jun 2014

3.2 Emergency Office Procedures Develop Emergency Office Procedures outlining how to deal with specific emergency situations that could occur in your office. Procedures do not have to be lengthy, but should be targeted toward your situation and needs, and should be in place and communicated with all of your staff before an event occurs. Always have both electronic and paper copies.

Your staff members need to be informed as to what to do before an event occurs.

It is a good idea to discuss these procedures in staff meetings to ensure awareness.

Everyone should know what to do in case of:

Your staff members need to know what to do before an event occurs.

It is a good idea to discuss these procedures in staff meetings to ensure awareness.

• Fire • Earthquake • Office disruptions or threats • Medical emergencies • Shelter-in-place • Utilities Refer to your workbook for specific steps to address each situation.

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CONSIDER THIS: You fall sick for a prolonged absence You’ve been handling a heavy patient load and burning the candle at both ends for a long time when you begin to notice extreme fatigue, fever, a sore throat, and swollen glands. You’ve developed a rash, lost your appetite, your muscles are sore, and you feel very weak. Tests reveal you have contracted the Epstein Barr Virus, and it could be months before you are well enough to work again.

Since you practice alone, there are many things to consider. What steps are required to file an insurance claim? Do you have a pre-arrangement with a locum or colleague who can care for your patients? How will your staff be affected? How will you maintain the income you need to live, pay your staff, and manage your practice?

How will you communicate with your patients, and ensure their smooth transition to another doctor’s care? Who will handle the overflow of administrative tasks? Who has signing authority in your absence? Who will pay your clinic’s bills such as power supply and internet services?

What else do you need to consider so that you are free to rest and recover, knowing your patient and staff needs are taken care of?

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3.3 Insurance Valid and adequate insurance can protect your practice from financial hardship and substantial losses. Every business carries insurance. When reviewing your insurance policies, at least annually, consider the following questions specific to practice continuity.

Send these questions to your insurance agent to help you with the process.

• Does your policy provide replacement value or current value?

• Will your insurance provide you with enough funds to bring your practice back to operation?

• Does your policy cover earthquakes, floods, and other natural events?

• Do you need business income insurance or business interruption insurance to help you cover your reoccurring monthly bills as well as payroll?

• Do you thoroughly understand the nature of earthquake insurance deductibles, and the difference between the deductible and damage amounts?

Keep your insurance information in a safe location — such as a fireproof, waterproof safety box or a bank safety deposit box — that will be accessible in an emergency.

This safety box should include: • your insurance company’s 24/7 phone number • your policy number • a copy of your insurance policy • type of insurance • photos or video of your practice and inventory • other important information and documents Keep at least two digital copies of these records off-site.

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CONSIDER THIS: Snowstorm Your city is being hammered by a nasty snowstorm, with 20 cm of snow on the ground, and winds blowing up to 75 km/h all morning. You, and most of your co-workers, left home more than an hour early to arrive at the clinic on time, but three administrative staff were unable to make it. Streets are slippery, many people are falling, and the extra workload — especially fielding calls from distressed and injured patients — puts a strain on the team.

Luckily, your property manager has cleared a safe access to the doors, but you are concerned about your frail and elderly patients who need to see you but who are immobilized by the storm. The clinic is much colder than normal because power has been intermittent. The phones are ringing at a high volume, but your EMR system is unavailable.

Although most of your records are stored digitally, you have several paper copies of your practice continuity plan, both in the office, and at home. It contains essential checklists and the critical information you need to keep your office running throughout the storm.

IT CAN HAPPEN: Doctors don’t take snow days—12 June 2011 Doctors and nurses brave brutal Boston blizzard to get to work—Boston, MA | 27 January 2015

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“Plans are often overlooked during emergency situations, but those who have at least thought about a plan are far better off than those who never do.”

KATJA MAGARIN | EMERGENCY MANAGER, B.C. MINISTRY OF HEALTH

3.4 Staff Contact List and Communication Plan Prepare a staff contact list, and indicate the order in which your staff needs to be notified and who will notify whom. At the bottom of page 15 (and also in Book 2: Workbook, Section 7.1) you’ll find a handy checklist of basic tasks for you and your staff. If a staff member has been assigned a specific task in the event of an emergency, include that task in this list. For example, your Office Manager could be assigned to notify all other staff, or patients who have appointments the next day. Consider cross-training staff on these

Prepare your Staff Contact List and Communications Plan using the template in BOOK 2: Workbook, Section 7.1

functions.

3.5 Identify Essential Services All practices have critical functions that support you to see patients (e.g., electricity, phone, water, etc.). Creating a list of essential services will help you to focus on the most important tasks when disaster strikes. Do you have staff members who absolutely must be available in an emergency, and can you cross-train to build resiliency?

Prepare your list of Essential Services using the template in BOOK 2: Workbook, Section 7.2

Your list of priorities will change depending on the type of emergency. Consider how soon you need these services available again and identify strategies to help you recover in the absence of each of your essential services.

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IT CAN HAPPEN: Prolonged power outages can be deadly for people who rely on durable medical equipment—29 Jul 2014

CONSIDER THIS: Prolonged power outage A strong storm has knocked several trees into power lines throughout the city.

You arrive at your practice to discover that there has been a power outage overnight, and your clinic is lit only by emergency exit lighting. You are not sure how long these lights will last, and your clinic does not possess a generator.

Unaware of WCB regulations against entering the premises, your MOA is already inside, having used the flashlight on her cell phone to enter the building. There is no light in the entire unit, the washrooms are windowless and completely dark, and the toilets are not flushing. From health, safety, and sanitary perspectives, it is unsafe to be inside.

Your telephones are not working, but neither of you know how to forward the lines to another number. You need to reschedule appointments with patients, and you are expecting important results from the lab. Most of your contact information is in your computers and inaccessible, with no paper backup.

You do have some contacts in your smartphone, but its battery is almost dead.

You’re also concerned about refrigerated or frozen vaccines, blood, and urine samples. What are some of the things you should do?

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3.6 Critical Records Inventory It is important to know where your critical files and information are stored, and how you can access them, especially when your practice becomes inaccessible. When thinking about vital records in your practice, ask yourself the following questions: •

Do you back-up your electronic information and files daily?

•

Is the back-up information stored at a safe external location?

•

Do you know how to access the information? Ensure you, and your staff, know how to retrieve the data.

•

What will you do if you have critical paper-based files that you cannot access?

•

Have you considered Freedom of Information & Protection of Privacy Act (FOIPPA) implications for storing documents?

3.7 External Services and Suppliers — Contacts All practices depend on a variety of external service suppliers that support you to see patients. Before disaster strikes, prepare a list with the key services these suppliers provide, their contact information and alternate phone numbers, as well as your account

Prepare your list of Critical Records using the template in BOOK 2: Workbook, Section 7.3

Prepare your list of External Services and Suppliers using the template in BOOK 2: Workbook, Section 7.4

numbers if applicable. Use the list to contact your suppliers and make any necessary arrangements to halt services post-disaster.

If you work in a larger office, you may want to designate one of your staff members as an authorized contact. In that instance, ensure the vendor is aware of the authorization.

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3.8 Updating Your Plan Indicate on your Practice Continuity Plan when it was last updated, how many copies were made, and where these copies are stored. Be sure to track amendments and updates. Also indicate how often the plan is scheduled to be reviewed, and who has this responsibility.

If you have an emergency that requires you to use the plan, it is recommended to set some time aside after you have recovered to see if you need to update your plan.  

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4. During and After an Emergency Retrieve your Practice Continuity Plan and begin implementation. On the following page you’ll find a helpful checklist to get you started. Always keep a log of your actions and activity, so you will have a record of the sequence of events and decisions made. Depending on the

It did happen and you actually have to use your plan. Now what?

Work through the checklist on page 16 (and in BOOK 2: Workbook, Section 7.5) to help you during an emergency.

event, not all steps may be applicable, or you may need to add a few more that apply to your office. Some steps must be taken in order, while others can be taken concurrently and are ongoing.

RAPID DAMAGE ASSESSMENT CHECKLIST collapsed/partially collapsed/leaning building cracks in walls or ceiling structural damage/beams or walls collapsed falling hazards (chimney, furniture, etc) ground movement/erosion/slope failure damaged services (electricity, gas, water)

4.1

Rapid Damage Assessment

In the case of an earthquake, you will need the tools to determine whether or not your workplace safe in which to practice. Consider obtaining Rapid Damage Assessment (RDA) training, which will help to identify unsafe conditions and to determine whether buildings can be reoccupied. Refer to your Workbook for more information about conducting a rapid damage assessment.

smell of rotten eggs (indicates gas leak) sparks or smoking broken glass/toppled furniture/other hazards

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Checklist  Stop and assess the situation

 Do you have enough supplies?

 Contact all key vendors and suppliers.

 Are you OK? Is your family OK?  Contact your staff members. Are they OK?

 Assess the damage and the extent of time your practice won’t be available.

 Contact patients who have appointments scheduled in the near future.

 Are you able to get to your office?

 Contact your landlord or property manager.

 Is your office available?

 Contact your utility providers.

 If the event occurs during office hours, protect yourself and your staff and evacuate immediately if necessary.

 Contact your insurance provider.

 After damage has been assessed by insurance firm, contact a salvaging or restoration company.

 Re-route phone calls.

 Obtain new office space.

 Re-route your mail and couriers.

You could use a PO Box.

 Determine equipment needs for your new office space.

 Document and track all your associated costs for insurance purposes.

 Contact all other patients.

 Do you have electricity, water, and heat?  Do you have access to a telephone?  Do you have access to your patient files, with their current email and phone contacts?

 Update your plan with the lessons you have learned.

5. Putting the Plan Together Now that you have identified your essential services, and inventoried your critical records and external service providers, it’s time to put your plan together: • Use the tables and forms in BOOK 2: WORKBOOK (book 2 of 2) to capture the information for your practice. Be sure to involve your staff.

• Keep several hard copies and electronic versions of the plan in different locations (e.g. one in the office and one off-site).

• Practice your plan annually.

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• Work with your staff to review and update your plan at regular intervals, but at least annually.

7. Resources WEBSITES & DATA Shakeout B.C. shakeoutbc.ca British Columbia’s Pandemic Influenza Response Plan embc.gov.bc.ca/em/hazard_plans/influenza-plan.pdf Earthquake preparedness in South Australia ajem.infoservices.com.au/items/AJEM-29-02-10 Pandemic influenza and physician offices bcmj.org/article/pandemic-influenza-and-physician-offices Primary care physicians’ response to pandemic influenza in Hong Kong ijidonline.com/article/S1201-9712(12)01179-4/ abstract?cc=y NEWS ARTICLES Arson destroys large part of Vancouver Island strip mall Sooke, BC | 31 Jul 2013 bc.ctvnews.ca/arson-destroys-large-part-of-vancouver-island-strip-mall-1.1392380 Early morning fire closes doctors’ offices Stratford, ON | 20 Jan 2014 southwesternontario.ca/news/early-morning-fire-closes-doctors-offices

Family doctors back in business after fire Stratford, ON | 7 Feb 2014 southwesternontario.ca/news/family-doctorsback-in-business-after-fire Christchurch earthquake: Latest updates New Zealand | 25 Feb 2011 nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=10708630 Wellington picking up the pieces post quake New Zealand | 22 July 2013 stuff.co.nz/national/8946666/Wellington-picking-up-the-pieces-post-quake Australian doctor receives bravery award for amputating trapped man’s legs after New Zealand’s 2011 earthquake New Zealand | 22 June 2014 abc.net.au/news/2014-06-23/australian-doctor-receives-new-zealand-bravery-award/5542746 Doctor reflects on Haiti’s ‘day of doom’ Haiti | 12 Jan 2015 bit.ly/1GkKuGP Flu back for round 2 Hamilton County, TN (US) | 19 March 2015 timesfreepress.com/news/local/story/2015/ mar/19/flu-back-round-2/294073 Number of influenza deaths in Alberta this season “higher than normal” Edmonton, AB | 29 January 2015 http://bit.ly/1FuesSj

Malfunctioning sprinkler system causes water damage to VA Big Spring, Texas | 14 Oct 2014 newswest9.com/story/26851316/malfunctioned-sprinkler-system-causes-water-damage-to-va Orillia City Centre sprinklers malfunction, flooding municipal offices Orillia, ON | 25 Jun 2014 bit.ly/1KEihst Flooding closes walk-in clinic for two to three weeks Kamloops, BC | 13 Feb 2013 http://bit.ly/1Jm6VvY Doctors don’t take snow days 12 June 2011 kevinmd.com/blog/2011/06/doctors-snow-days. html Doctors and nurses brave brutal Boston blizzard to get to work Boston, MA | 27 January 2015 mashable.com/2015/01/27/doctors-nurses-boston-blizzard Prolonged power outages can be deadly for people who rely on durable medical equipment 29 Jul 2014 huffingtonpost.com/nicole-lurie-md-msph/prolonged-power-outages-c_b_5405068.html

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NOTES FIRE IN THE BUILDING____________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ EARTHQUAKE ___________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ PANDEMIC ______________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ SPRINKLER MALFUNCTION _______________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

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NOTES PROLONGED ABSENCE DUE TO ILLNESS ____________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ SNOWSTORM/ENVIRONMENTAL INTERRUPTION ____________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ PROLONGED POWER OUTAGE/UTILITY INTERRUPTION _______________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ MISCELLANEOUS_________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

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Produced September 2015 | Victoria Division of Family Practice | divisionsbc.ca/victoria